Diagnostic concerns in fluency disorders

1. Diagnostic concerns in fluency disorders

2. Fluency Assessment

3. Assessment Overview

4. The goals of a fluency evaluation For young children: Do they stutter? Developmental stuttering vs. normal disfluency vs. language formulation disfluency If they stutter, how likely is recovery? � examination of risk factors What is the appropriate next step? Monitoring, parental consultation Indirect management Direct management For older children and adults: How significant is the stuttering problem? In terms of overt symptoms In terms of associated behaviors, including frustration, fear, avoidance, and perceptions of handicap and disability What factors affect fluency and associated affective and emotional states? What are the goals of fluency therapy?

5. Appraising overt symptoms: the speech sample From children: Conversation with you and with the parents Narrative (e.g., �Frog� stories) Recreation of situations/contexts in which fluency is reported to wax and wane From adults: Monologue (may be done during case history) Conversational interaction Reading Optional: appraise consistency and adaptation using repeated reading of materials

6. Tallying disfluencies (overt behaviors) from the speech sample What gets counted? Normal disfluencies Stutter-like disfluencies (SLDs) Calculating proportions � what are your numerators and denominators? Appraising frequency Via percent stuttered words or syllables Problems with purely time-based measures Describing typology What are the proportional incidences of major disfluency subtypes? Reliability of behavioral measurements � Tom exercise

7. Examining accessory features A tip: listen to the tape without looking, then look without listening Things to look for: Atypical speech production postures Ancillary body movements Eye gaze Sample assessment instruments: SSI-3, Cooper Scales

8. Attitude assessment Potential measures: See sample handouts How does stuttering affect the individual�s everyday behavior? What are perceptions of disability and handicap? How do they feel about speaking and stuttering? What do they know or believe about their stuttering?

9. Goals of the assessment For parents, what are the goals? Can they supply more than one? Using goals to explore options What are the client�s goals?

10. Dx summary � preschool children Questions that need to be answered: Is it stuttering? What is the likelihood of spontaneous recovery? What has been done up to now, with what results? What are the pro�s and con�s of various treatment models?

11. Preschoolers (continued) Information required: Frequency, duration and types of disfluency Presence of struggle or tension Presence of awareness and reactions to moments of disfluency Assessment scales (see handouts) Status of other speech/language abilities Parent-child communicative style Parents� reactions and attitudes toward behaviors Parents� understanding of the nature of stuttering Perceived risk factors for chronicity or worsening of symptoms

12. Preschoolers (continued) Case history specifics: Parents� information about onset, course of disfluency patterns over time Medical, social and developmental history Child and listener responses to disfluency Level of awareness, frustration, avoidance, self-consciousness Reactions of others in the child�s environment, including advisements Parents� beliefs about cause of the problem Parents� views of the child�s personality and temperament Family history of stuttering and other communicative disorders

13. Behavioral measures for pre-schoolers: What are SLDs? Stutter-like disfluencies include: Sound, syllable and monosyllabic whole word repetitions Weighted scores for disfluency take into account the number of iterations Blocks, prolongations, broken words Other disfluencies might include: Interjections, filled pauses Revisions Multisyllabic word or phrase repetitions Hesitations

14. Step Two: Assess predictors of remission and chronicity The facts: ~80% of children who begin to stutter will recover (apparently without clinical intervention) The time frame for remission may be more limited than previously supposed (Yairi, et al., 1996; Ramig, 1993)

15. Predictors of chronicity and remission*

16. Weighing the odds

17. Patterns to monitor

18. �Watch and see�, not wait and see As in SLI, the rapid course of remission, but uncertain future of individual children requires the partnership of parents and clinician to actively monitor progress and establish guidelines for implementing intervention (Paul, 2000)

19. Dx summary: school-aged children Questions that need to be answered: How complex has problem become? (awareness, shame, guilt, self-image as a CWS?) Is any part of problem language-based? What are relative contributions of physiological factors, psychological factors, attitudes and learning? What is child�s perception of problem? How does it compare to the parents� perceptions? What intervention strategies would be most beneficial? In what capacities will parents/school be involved? Educational component Coordination of services

20. School-aged children (continued) Information required: Medical, developmental, social and educational history Full understanding of speech/language abilities Frequency, duration, concomitant behaviors Impact on emotional development Parental/family/school reactions and attitudes toward stuttering Child and parents� understanding of the nature of stuttering Previous speech therapy: approaches and outcomes Listener reactions and responses to listener reactions

23. School-aged children (continued) Parent interview: similar to that of preschoolers; adjust to be age-appropriate Teacher interview General questions about achievement and social development How does stuttering affect these areas? Reactions of students and staff to stuttering? Child�s reaction? Level of participation, verbally and nonverbally in classroom and other school activities Information about services received at school

24. School-aged children (continued) Child interview Move slowly until you assess how direct or open the child would like the interview to be Child�s perception of the problem � what does he call it? Child�s perception of parents� perception of the problem Child�s description of the problem How much does stuttering bother the child? What does the child do to cope with or escape from the moment of stuttering? Experiences with peers: teasing, support? Assessment scales (see handouts, e.g. CALMS model) Attitude scales: CAT (DeNil & Brutten)

25. Tips for interviewing young children Some basics: Don�t be alarmed if child says, �I don�t know� or shrugs shoulders. Children are not used to evaluating feelings. They don�t necessarily evade. Some children just accept things the way they are. Share something about yourself, and the type of work you do: �One of my jobs is to help kids talk better�

26. Talking to young children (continued) Use analogies and examples to help the child feel comfortable talking about problems. For example, �One of my friends who comes to play with me is Josh. He sometimes gets stuck when the teacher asks him to read to the class. Does that ever happen to you?� Use a marble maze with some marbles too large to flow freely. Have some get stuck. Then say, �This marble is s-s-s-stuck. That picture on the wall was made by Josh. It shows how he crunches up his face when he gets stuck. What kinds of things do you do?�

27. Some questions to ask young children Whom do you like to talk to? (At home, at school) Who talks the most/least (At home, at school) Who interrupts? Who do you interrupt? Who are good talkers? When do you want to talk well? Are there times you want to talk extra well? Do other people feel this way as well? When do you want to talk more than you do? Who listens/pays attention? What do you like listeners to do when you talk to them?

28. Qualifying children for services in the schools Please see diagnostic considerations for qualifying CWS under IDEA and writing IEPs (separate handout).

29. Dx summary - Adults Questions you need to answer: What type of fluency disorder is it? Developmental stuttering Cluttering Neurogenic stuttering Psychogenic stuttering If developmental stuttering, what are the relative contributions of physiological, psychological, attitudinal factors and learning? Why does the client seek tx now? � goals? How does disfluency affect client�s communication and life? What intervention strategies will be most appropriate?

30. Adults (continued) What information will be needed? Disfluency types Severity of the disorder Percentage of disfluencies Concomitant behaviors Fears and avoidances Client�s attitude toward disorder Core and secondary behaviors Emotional reactions/attitudes Social, vocational and lifestyle information

31. Adults (continued) Interview specifics: Onset and early development; how was stuttering handled in family? What does client believe caused it? Impact educationally, socially and vocationally Outlook: hope for change, past tx experiences, motivation to change Patterns of recovery and relapse, situational variability Family history Level of fear of speaking and stuttering Avoidance patterns Self-perceptions

32. Adults (continued) Measuring impairment, disability and handicap (Yaruss & Quesal) Speaker�s reaction to stuttering Functional communication Quality of life

33. Measuring speaker reactions: tools Watson (1998) Inventory of communication attitudes Ornstein & Manning (1985) Self-Efficacy Scale (SEA-Scale) for Adults who Stutter Andrews & Cutler (1974) � adaptation of Erickson�s S-Scale Yaruss & Quesal (2000)

34. Diagnostic interpretation For children Provide data on prognostic indicators, and work with parents to determine next steps, which should include a minimum of active monitoring and counseling to palliate symptoms. Introduce information about therapy approaches Provide information and information sources to help family explore stuttering.

35. For adults: Explain the therapy approaches that you offer, and explore acceptability to client. Is this what the client had in mind? Negotiate the �terms� of therapy Help them become informed consumers; provide information sources.